Tibia rotational alignment in total knee arthroplasty: Delphi consensus statements from European Knee Society (EKS)

Rotational alignment of the tibial component during total knee arthroplasty (TKA) is critical for ensuring optimal tibiofemoral and patellofemoral joint function. Proper alignment minimizes the risk of tibiofemoral mismatch and patellofemoral instability, which can lead to increased joint stress and compromised kinematics. Traditionally, the tibial tubercle axis (TTA) has been the primary landmark for alignment. However, recent insights into knee three-dimensional anatomy reveal significant variability in TTA positioning, challenging its reliability. This study employs a Delphi consensus methodology among European Knee Society (EKS) experts to address key questions regarding tibial rotational alignment in TKA. Through a systematic literature review and expert discussions, a strong consensus was achieved on three main points: (1) optimal alignment should target both the perpendicularity of the anteroposterior tibial axis to the femoral flexion/extension axis and the accurate positioning of the tibial tubercle relative to the femoral trochlea; (2) while the TTA is effective in 70% of cases, its variability in 30% of knees necessitates alternative strategies; (3) current computer-assisted and robotic technologies do not significantly enhance alignment outcomes. These findings emphasize the importance of individualized assessment of rotational deformities and highlight the potential of advanced data analytics to improve future alignment strategies. The consensus underscores the complexity of achieving optimal tibial alignment and the need for continued research to refine surgical techniques and technologies.